Expert Q&A: Everyone plays a role in improving cancer health equity

Equity in cancer care has long been an important theme for Lori Pierce, M.D.

She made it a focus as president of the American Society of Clinical Oncology in 2021.

So when the editors of The Cancer Journal selected health equity in cancer care as the topic for a recent special issue, Pierce, professor of radiation oncology at Michigan Medicine, was the ideal choice for guest editor.

“We can and must serve as advocates for our patients and give a voice to their stories and the barriers they face when they are unable to express their issues and concerns themselves,” Pierce wrote in her guest editor piece for a special issue of The Cancer Journal.

She pulled together an all-star list of researchers who focus on inequity in cancer management and policy to contribute articles on wide-ranging topics: cancer control policies; exposure to stress among African Americans; how structural racism and implicit bias have led to unequal access to health care resources; diversity in the oncology workforce; clinical trial participation; cancer prevention.

“Cancer survival rates over recent years have shown improvement across races and ethnicities, so by acknowledging and addressing barriers to care, further improvements toward equitable access, treatment, and outcomes can be realized for all,” she wrote.

“It is imperative that we get this right. The stakes are far too great if we don't.”

The issue digs deep into breast, lung, prostate, colorectal and gynecologic cancers as the most common cancer in the United States, and the most common causes of cancer death.

Sherri Sheinfeld Gorin, Ph.D., professor of family medicine at Michigan Medicine, led a review of cancer prevention strategies.

Here, Pierce discusses potential solutions and paths forward to improve equity for all in cancer care.

The articles address many factors that have exacerbated health inequities – access to screening and care, tumor biology, quality of care, awareness. While these are all very complex issues, do you see any low-hanging fruit? Is there something that providers, researchers, communities or individuals could do right now to make an impact?

Pierce: Great question. Clinical researchers must continue to identify inadequacies in screening policies and treatments that disadvantage one population relative to another.

We must have screening trials that include diverse participants so the results can be generalized to diverse populations. We must not simply analyze trial results by race, discover a negative outcome for certain races, and then stop there.

That should be the starting point for further study.

Race is only a social construct, so if there are less favorable outcomes for a particular racial category, it is our responsibility to push to understand why.

Is it biology? Is it a product of the social determinants of health? Is it both? Only though understanding the causes of less favorable outcomes can we propose meaningful solutions.

As physicians and members of the cancer care team, we must take the time to explain clinical trials and the processes for accrual to patients and their families, and we should never assume that individuals will have little interest in participating.

Data show that when asked to participate in cancer clinical trials, patients do so at equal rates regardless of their race or ethnicity.

As cancer providers, it is imperative that we discuss cancer prevention strategies.

Up to 50% of cancers are estimated to be preventable with the promotion of healthy lifestyles. And we must work with our primary care colleagues to be sure cancer screenings are scheduled per national guidelines or earlier, depending upon patient history.

We all should advocate for equitable cancer care on behalf of our patients to local and national legislative bodies to increase awareness of systemic inequities and the need for change.

And finally, health care providers and community members should maintain a constant dialogue regarding screening recommendations and healthy lifestyles to promote early detection to maximize cure. For these discussions to occur, we, as providers, must promote relationships based upon trust.

Where have we seen the most progress in addressing cancer care inequities?

Pierce: An exceptional example of not only reducing cancer care inequities by race but actually eliminating differences in cancer outcomes is the Delaware colorectal cancer screening program.

Leadership in the state of Delaware were aware of the discrepancies in the rates of colorectal cancer screening between Blacks and whites and the resulting higher rates of death from colorectal cancer among Blacks relative to whites.

They started a program that brought together many constituents across the state, including cancer and primary care physicians, politicians, social workers, patient navigators and community-based organizations to develop an action plan that included providing resources for those who were uninsured.

By doing so, they removed the barriers to colorectal cancer screening and treatment.

These efforts have resulted in equal rates of screening and equal outcomes by race.

This program is a model for how partnerships between communities, physicians and governing bodies can change the direction of cancer care to eliminate treatment inequities. This should – must – be replicated by others.  

What’s your vision for 5-10 years from now? How do you hope cancer care will have changed in terms of health equity?

Pierce: Cancer care is one aspect of medical care.

For cancer care to change, medical care in general must change. Perceptions and racial biases by health care personnel must change.

That requires acknowledgment that biases exist that subconsciously affect medical decision-making. That requires awareness that many historic medical policies disadvantage one group relative to another.

Based upon recent social events, there has been increasing awareness of inequities that affect medical care overall and, in turn, cancer care.

These events have increased the consciousness of racial inequities in medicine.

This awareness is a necessary step toward understanding and demanding change.

It causes one to analyze outcomes based upon the policies in place and change those that undermine health equity. It creates a greater accountability to those who govern to level the playing field for all.

In cancer, that means looking at the polices that determine cancer care reimbursement and increasing resources to those who are uninsured, similar to the Delaware program.

It means providing screening opportunities that do not differ by race or financial status but rather focus on cancer incidence rates by age, location and social circumstance.

It means participation in cancer clinical trials for patients of all races and ethnicities in percentages equal to or greater than those in the general cancer population. And it means adherence to published treatment guidelines regardless of race and ethnicity.

We are indeed seeing improvement in cancer outcomes as cancer survival rates have increased for patients of almost all races and ethnicities.

The survival rates are, however, significantly lower for many under-represented minorities. But the positive trajectory is clear.

The stage is set. With continued dialogue among all critical constituents, I hope we will see significant improvements in rates of screening and treatment independent of race and ethnicity, and thus significant reductions in the rates of cancer deaths for minority cancer patients over the next five to 10 years such that outcomes are comparable for all.

Paper cited: “Building a Bridge to Equity in Health and Health Care in Cancer Care,” The Cancer Journal. DOI: 10.1097/PPO.0000000000000690